**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure residents were free from significant medication errors when medication orders were incorrectly transcribed, not reconciled and incorrectly administered for 1 of 3 sampled residents (Resident 1) reviewed for significant medication error. This caused harm to Resident 1 when the resident was administered potent medications not prescribed and had a serious change of condition requiring hospitalization. This failure placed residents at risk of adverse reactions to medications, change in health conditions and a diminished quality of life. Findings included . Review of the facility policy, dated 07/2015 and revised 11/2023, showed: admission orders will be obtained/approved through the Provider as soon as possible following or prior to the resident admission/re-admission to the center . Staff will review medication orders and assure standards of practice with orders to include the following: - Right route, dosage, frequency. - Stop dates for antibiotics - Each medication has a corresponding diagnosis - PRN (as needed) Psychotropics have 14 day stop date Resident 1 was admitted to the facility on [DATE] with diagnoses including weakness, stroke, and history of elevated blood pressure. The admission Minimum Data Set assessment, used by the facility to complete the plan of care, was pending prior to discharge on [DATE] to the hospital. Record review of the hospital physician encounter note, dated 02/13/2024, showed on 02/11/2024 the resident reportedly received the wrong medications and noted to have decreased level of consciousness, difficulty breathing and coffee ground emesis. Resident 1 was transported to the hospital emergency department and admitted for treatment. Review of Resident 1's medical record showed medication errors were discovered after the resident's change in condition following the morning medication pass on 02/11/2024. The facility investigation showed Resident 1 received medications ordered for a non-facility resident (NFR) and the admission medications for Resident 1 had not been verified per protocol by two nursing staff. After the error was identified, the correct orders were then obtained from the prior discharging hospital and placed in Resident 1's medical record prior to the resident's readmission back to the facility on [DATE]. The after-visit summary, dated for the initial hospital discharge of 02/09/2024, showed 10 medications were ordered for Resident 1, and were not started on admission to the facility, that included: = Acetaminophen 325 milligrams (mg) - 2 tablets as needed every 6 hours.(pain relief) = Amlodipine 5 mg daily (high blood pressure) = Aspirin 81 mg daily (stroke prevention) = Atorvastation 40 mg every night (high cholesterol) = Bisacodyl 10 mg suppository as needed daily (laxative) = Colace 100 mg twice daily (laxative) = Famotidine 20 mg daily (ulcer, esophagus, digestive treatment) = Lidocaine 4% patch apply on skin every night (pain) = Miralax 17 grams (g) daily as needed (laxative) = Senna 8.6 mg one tablet twice daily (laxative) The after-visit summary, dated 01/31/2024 through 02/08/2024, showed a NFR's name clearly listed on the top of the summary and included a recap of the NFR's hospital stay. The summary for the NFR showed the following 20 medications were erroneously documented on Resident 1's February 2024 Medication Administration Record (MAR) and were initiated by nursing on 02/09/2024: = Aspirin 81 mg one daily (pain) = Ciprofloxacin HCI 500 mg tablet. One tablet every 12 hours for 3 doses (antibiotic that had a *black box warning* - often referred to as simply boxed warning - is the strongest warning issued by the FDA in the United States on drugs that carry specific health risks - serious or life-threatening adverse effects). = Fludrocortisone 0.1 mg tablet 1 tablet daily (for adrenal gland diseases) = Tamsulosin 0.4 mg one every morning (for prostate urine flow problems) = Acetaminophen 325 mg take 2 tablets every 6 hours as needed (pain) = bisacodyl suppository 1 daily as needed (laxative) = Bupropion 150 mg tablet every morning (antidepressant with a *black box warning*) = Carbidopa-Levadopa 25-100 mg 2 tablets four times daily (a medication for Parkinson's, central nervous system disorder affecting movement, with a *special precautions noted for potential side effects of coffee emesis, bloody stools*) = Cholecalciferol 1000 unit tablet. Take 2 tablets every morning (vitamin) = Finasteride 5 mg tablet. One nightly (medication for a prostate disorder that is *not approved by the Food and Drug Administration for use in women*) = Guaifenesin 100 mg/milliliters(ml) Take 10 ml every 4 hours as needed (decongestant) = Lactobacillus Rhamnosus 10 billion cell capsule. Take one every morning (supplement for gut health) = Lidocare 4% patch. Place on skin as needed (pain) = Loratadine 10 mg tablet every morning (allergens) = Melatonin 3 mg tablet once nightly as needed for healthy circadian rhythm (rest) = Multivitamin one daily (supplement) = Miralax 17 g daily as needed (for constipation) = Pravastatin 40 mg one each night (cholesterol lowering) = Sertraline 100 mg Take 2 tablets every morning (an antidepressant with a *black box warning*) = Vitamin B-12 1000 micrograms (MCG) one tablet every morning (supplement) Review of Resident 1's February 2024 MAR showed on 02/09/2024 through 02/11/2024 the following medications on Resident 1's original order were omitted when not transcribed and were not given: = Amlodipine 5 mg - Omitted two days. = Famotidine 20 mg daily - Omitted two days. = Lidocare patch - Omitted. = Colace 100 mg twice daily - Omitted. = Senna twice daily - Omitted. Review of the February 2024 MAR showed on 02/09/2024 through 02/11/2024 Resident 1 erroneously was administered the following medications that were prescribed to the NFR, not to Resident 1: = Bupropion HCI ER 150 mg - Received two days. This medication had a *black box* warning. = Cholecalciferol 25 mcg - Received two days. = Cyanocobalamin 1000 mcg - Received two days. = Finasteride 5 mg - Received one PM dose. = Fludrocortisone 0.1 mg - Received two days. = Loratadine 10 mg - Received two days. = Multi Vitamin - Received two days. = Pravastatin 40 mg - Received one PM dose. = Probiotic (gut health) - Received two days. = Sertraline 100 mg/take 200 mg each day - Received two days. This medication had a *black box* warning. = Tamsulosin 0.4 mg - Received one PM dose. = Cipro 500 mg - Received three doses. Resident 1 was allergic to medication class. This medication had a *black box* warning. = Carbidopa-Levadopa - Received two days, six doses. On 02/23/2024 at 1:40 PM, Collateral Contact (CC) 1, Confidential Source, said the facility reported to them, on 02/11/2024, Resident 1 had received the wrong medications causing a change in condition that required hospitalization. At 1:20 PM, Staff A, Resident Care Manager, said when Resident 1 was admitted to the facility the discharging hospital failed to include the medication list. Staff A said after the facility requested the papers, the orders were uploaded, entered offsite, and not verified by two nursing staff per facility protocol. On 04/01/2024 at 12:38 PM, when asked how Resident 1's medication errors were discovered, Staff B, Licensed Nurse, stated, It was just a fluke. Staff B said he was giving medications and another nurse pulled up Resident 1's medications. They looked into documentation and did not see where two people had checked the resident's record. Staff B said Resident 1 had received her morning doses of medications, had a change in condition, was not feeling well and had an episode of coffee ground emesis. Staff B said Resident 1 was transported to the hospital for treatment. The incorrect medication list was discontinued once the medication error was identified and the correct medication list was requested from the discharging hospital. Resident 1 was transported to the hospital for attention and evaluation for a significant change in condition and after learning she was administered the wrong medication. The facility completed a fully facility audit of all hospital transfer order to ensure accuracy. Immediate education to nurses regarding two patient identifiers as well as re-education on admission policy occurred on 02/11/2024 and 02/12/2024. An audit tool was created for IDT to review in daily clinical meetings and to be completed on every admission. The admission Resident Care Manager (RCM) and Director or Nursing (DON) or designee will audit admission orders and the audit tool for 12 weeks and review results in QAPI. The admission RCM and DON will be responsible for ensuring compliance. This was Past Non-Compliance. Reference WAC 388-97-1260 (3)(k)(iii) .